2.1.13

Daniel has diabetes.  A generous foundation in Australianow provides Daniel and other children at JDJ Hospital with all the insulin and testing strips they will need.  But recently, we discovered that Daniel was starving to death.  His disease makes it impossible for his body to consistently use simple sugars well to nourish it and grow, yet it is only simple sugars that Daniel eats:  rice, corn, bread, juice.  Why?  Put simply, Daniel is poor.  His grandparents daily forage for food at the market leaving Daniel at eight years of age home alone to prepare meals for himself.  Daniel needs a regular supply of protein from meat, fish, leafy vegetables and beans.  This will cost about one dollar and fifty cents a day, so the price of Daniels life for three months we put at $135.  Daniel is an awesome kid who is quiet, polite but teaming with emotion just waiting to erupt.  Help Daniel get consistently nutritious meals and follow Daniel's progress through this site.

12.22.13

Daniel was discharged from JDJ today.  This is the third time he's been admitted to the hospital with DKA this year-- life-threatening high blood sugar and acidosis due to inadequate endogenous insulin.  We know Daniel has enough exogenous insulin because he comes to Diabetes Clinic every other week for his supply and the other patients are doing well.  My theory is that Daniel is still competing with his ten brothers and sisters for food.  Since food is inconsistent, he knows if he gives himself his full dose of insulin he will feel bad (and it may kill him) so he reduces the dose or dispenses with it all together.  Then all of the sudden there is food and Daniel binges.  His sugar sky-rockets and so begins the steady spiral.  A truly vicious cycle.   Augustine and I have not given up.   We are going toteach Daniel how to dose his insulin according to the carbohydrates he actually eats.  But he has to get his three meals.  Daniel is as skinny as a stick.  I think the meals are going to have to come in school.

3.15.15

Daniel whispers to me that he cannot wait to go back to school.  We talk about how the President is rumored to be on the verge of declaring Liberia Ebola free and thus education back open for business.  It's about time. Is having an entire nation of children at home for ten months safer? It's not like the children stay at home.  

Daniel is okay.  I finally have a diagnosis for his distended abdomen and swollen facies. It's called Mauriac syndrome and it's a sign of uncontrolled diabetes in adolescents.  All these physical manifestations can be reversed with proper sugar control.  That's the good news. The bad news is that unless we are able to buy enough food for the other eight children in his family, Daniel will always be food insecure and his sugar difficult to control.  Luckily, the consequences of blindness, compromise to peripheral circulation and heart disease do not seem to occur until after adolescence.  Daniel is 14.  In three years, technology will have to catch up in this country-- insulin pumps, beta-islet cell transplants, cultural specific calorie counting. There is no other way.

1.10.16

I thought about Daniel the other day when a mother in a California hospital where I was working showed me an insulin pump attached to her abdomen and a glucose reader attached to her arm. Using today's technology, she doesn't have to dose her insulin at all. The glucometer signals in real time her glucose level to the pump, which in turn infuses the correct volume of insulin. No more pricks! No more dosing errors!  No more short and intermediate acting insulin mixture!  

I rarely believe in technological fixes to anything of substance, but alas, in the case of Daniel's diabetes, this is what Daniel needs.  He has for years lost the fight for food in his family.  He therefore cannot dose his insulin based on his metabolic needs-- the whole point of insulin therapy.  Consequently, his sugars are all over the place and Daniel can and has become quickly and deathly ill.  Daniel remains humble.  In the five years I have known Daniel, he has never admitted to being hungry when I know he is often starving.  

"You already eat?" I ask.

"Yep," he always says. 

Then we go to eat.

9.11.16

The details are murky but dear Daniel passed away today.  This language makes it sound like Daniel's death was peaceful but it likely wasn't.  For one, he was admitted to the hospital for severe malaria which is a paradoxically painful and exhausting disease.  Second, he was cared for by medical personnel who didn't understand he had insulin dependent diabetes, which was the more important disease to treat.

Daniel's death is all at once sad, overwhelming and expected in the day and life of a boy in Monrovia, Liberia.  There is life everywhere there but tragedy abounds too. We tried very hard to protect Daniel over these years, but in the end we failed.  He was a kind gentle boy and in a way was really just waiting to begin.

Daniel leaves behind his grandmother, grandfather and eight brothers and sisters.  Rest in peace, dear Daniel.

School a Princess for a Year

3.20.13

We discovered when we were filling out Princesses forms for our new diabetes clinic that she neither had a birthday nor a school.  Princess had been born during Liberia's civil war and the time and horror of it subsumed the celebration of this new baby's life.  Princess is  grown up.  When she became sick with diabetes, her step-mother took her out of school because she was scared.  Besides, money was tight.

So we gave Princess a birthday (January 13th) and her first ever party at the hospital equipped with presents and crown hat to boot.  We told her how much we loved her which meant in large part sending her back to school.  Princess was ecstatic.  

Help educate Princess and watch her learn through this site.

1.15.14

Princess is growing up.  She actually asked me (through Augustine) for tuition.  "This woman needs to go to school," she said.  I am most proud of Princess for helping with the younger kids in diabetic clinic.  She comes to diabetes clinic each week to give moral support and especially looks after Daniel when he is sick.  I am hoping that she helps us figure out what is wrong with our care of Daniel.  None of the other patients including Princess have been treated in the hospital for DKA since joining the program.  Maybe Princess can learn Daniel's secrets or the other way around.

3.15.15

The Ebola epidemic has meant that Princess is out of school like the other children.  The nation if not the world is wondering when the President will decide that it's safe to resume a normal life which seems harder and harder in Liberia.  But Princess is her normal self: Cheerful, in regular attendance at the clinic, and shy. 

I admit worrying about Princess beyond her diabetes.  She only speaks when spoken to and her responses are never elaborate.  I she is this way partly out of respect and partly because she still regards me as a "white man", even after four years.  Of course I tell Princess that I am Taiwanese-American but she has yet to act on the difference.  So we are still working on Princess and our hopes and wishes persist to rest on her.

2.15.16

The insulin shipment finally arrived!  The last shipment was never sent so Augustine has had to buy insulin out of pocket for months for the now twelve children in the clinic, including Princess whom we won't be able to refer to as a child for much longer.  I really have to pause to give thanks to Life for a Child Foundation which provides our make-shift diabetes clinic with free insulin and testing supplies. Without the foundation, frankly, I would be much poorer or the children not alive. The cost of one month of insulin exceeds the income of most of the families. Sometimes you need things taken away to be grateful.

To Princess, Daniel and the other children and Augustin, George and other volunteer staff, who help take care of them.  It's been five years and counting!  I have been there and it's still hard but great to believe.

Educate Liberia's 201st Doctor

3.20.13

Augustine is one of the smartest hardest working Liberians I have ever met.  I met him when we lived in Liberia.  He was a nursing assistant at JDJ Hospital where I used to donate my time on Saturdays.  Seeing his potential, I quickly hired him into the IRC and for almost 2 years we became the Batman and Robin of medical quality assurance.  Believe me, this was more exciting than it sounds.

Liberia has 150-200 doctors in the whole country.  That'sa doctor to patient ratio of 1 to 25,000.  The ratio in the United States is 1 to 350. Accordingly, 10% of all children don't live to celebrate their 5th birthday and 1 in 120 women die during childbirth.

I've decided that Liberia needs another doctor and his name is Augustine.  He might as well get the title since he is single-handedly running and literally feeding the JDJ diabetes clinic.  

Contribute to Augustine's medical education and watch his development as a medical professional here.

1.15.14

Augustine didn't get into medical school-- twice.  He started pharmacy school and I said what the hell.  Pharmacy is boring and honest, Liberia doesn't have a regular supply of drugs unless you mean the black market.  Not a promising career at all.  

I haven't given up.  I am having Augustine take a diagnostic MCAT test and just sent him Princeton review books through my friend Michelle.  The thing is the guy is so dastardly confident I can't imagine what is wrong.  But medical tests are medical tests.  Medical entrance is dependent upon medical tests so we will know a lot more soon.

The new test date is this May.  There is still time.

7.4.14

Augustine's test for admission into medical school is anytime now.  He's registered, the test is in July but there is no public announcement about the actual date.  This tells you something about Liberia.  I've sent Augustine all of the MCAT tests from the past six years and wired money so he can study while out of work.  Augustine lost his job last December.  "You better get in," I joke, "I can't afford you much longer."  I have decided that Western Union is a price gouger.

Its kind of strange talking about the MCAT in the "Liberian context" as international health bureaucrats like to say to absolve themselves of responsibility.  The MCAT is an American medical exam but Liberia uses sections derived from it.  In the U.S., good performance on the MCAT is one of the many criteria for admission into medical school. In Liberia, so few people are qualified to take the test, the top forty MCAT scores is the sole criteria for medical school admission.  My experience is that you study for this test by taking the test over and over again.  You identify the concepts you don't know from missed questions and tackle them directly. Oh, and you try to enjoy the process.

Meanwhile Ebola Virus has just killed one doctor and two nurses at Redemption Hospital.  Our own dear Dr. Jude is under quarantine.  Dr. Jude is the man I tried to convince to take over my job as Health Director for the International Rescue Committee - Liberia before I left in November of 2012.  He refused because he still had unfinished business at Redemption.  The death toll from Ebola, which Doctors without Borders declared last month out of control, has risen above 60.  Thank goodness that both Dr. Jude and Augustine are still safe. Let me rephrase, Augustine has to get in. 

3.16.15

Of course the medical school test that Augustine took last fall has yet to be corrected.  The Ebola epidemic put all sane activities permanently on hold and of course we started with the Liberian Medical Education System as a base-line.  Thank goodness we were able to get Augustine back on staff with the IRC. Check that, he got himself back on but at least I was able to facilitate a few introductions. 

To amuse me, I still make Augustine go to the medical school behind Catholic Hospital periodically to see if there are any updates, even though the answer is always the same:  Check back in a month.  IRC is a wonderful organization but sometime I feel international aid is a dead end for national staff.  Besides, having doctors constantly come in from the outside to support Liberia's medical system cannot be part of any satisfactory master plan.  Most of these doctors end up leaving before they can even get close to understanding the dynamics and environment of the workplace necessary for being effective.  There are no guarantees but the likelihood of a Liberian physician making a long term difference here exceeds that of a foreign one any day.

11.15.15

Augustine just left the U.S.  After two years of trying, he finally made it.  Lesson #1.  Anything is possible, even with U.S. Embassy services. Lesson #2.  If you intend to visit the U.S. as a foreigner, best have more than $100 in the bank and a job.

My main reason for bringing Augustine here was to reward him for all the work he's done on behalf of the kids, to let him see another context and its contents to help him assemble his personal and professional data points and to give Augustine his first vacation! I know, the last point is hard to believe, especially relative to someone like me.

Suffice to say, Augustine had a great visit.  I will write more about this visit in depth shortly, but one recounting:  When I asked Augustine what he liked most about his two and a half week time in the U.S., he said without hesitation the American Public Health Association conference in Chicago for the "quality of presentations" and the "diversity of efforts" being share.  Augustine never ceases to amaze.

11.20.16

Augustine is rethinking whether he can become a doctor.  The Ebola epidemic devastated Liberia's medical education system.  It's been over a year since Liberia was declared Ebola "free" but the nation's only medical school is still closed.  And the Director just quit for Ghana.  And at its peak, the school only graduated 14 students a year.  

I want Augustine to pursue his dreams but dreams in Liberia are often deferred.  He could go to Uganda or Ghana for medical training but the former is really far and expensive and the latter very competitive and its quality unknown. What to do?

Augustine talks of business school or public school but I am unconvinced what these degrees give him.  He will do more research on the options and get back to me. In the meantime, Augustine continues to work for the International Rescue Committee (IRC) on emergency response to infectious disease threats.  Sometimes it feels like in Liberia that its Ebola or nothing.

12.8.17

Augustine ended work with the International Rescue Committee (IRC) May 2017.  He had worked for the IRC for six years. Though I understand all good things must come to an end, I was frustrated that the IRC couldn't find a place for someone as smart, experienced and hardworking as Augustine. 

Augustine now is doing some international health contract work and of course managing the diabetes clinic.  My new idea for him is to help me advance the case for electronic health data management in Liberia given the scarcity of doctors and almost 100% reliance on paper and pen for medical record keeping.  This combination produces medical error rates in the 50-80% range and as you can imagine very high rates of preventable tragic death.

So Augustine's clinic is currently running the Walking Doctors Electronic Health System!  It is the only use of electronic medical record keeping and linking, let alone decision support in the entire country.  After a short period, we will package our results into a proposal to help support the clinic, Augustine (until that dastardly Medical School reopens) and the need for impactful health technology designed by folk who have worked and lived in Liberia.